Patient Referral Authorization Form
TRICARE referrals should be submitted through (log
on to Self-Service for Providers). If you do not have internet connection in your
office, you may complete and submit this form by fax to 1-877-548-1547.
The Military Treatment Facility (MTF) in your area may have Right of First Refusal for this service.
TRICARE ID
Patient Name
9-11 Digits
Patient DOB
_
_
_
Patient Zip Code
MM-DD-YYYY
Address
City
State
Other Health
Yes
_
_
Phone
Carrier
Insurance?
No
Policy#
Provider or Setting
Physician's Office
Allied Health Professional's Office
Outpatient Facility
Inpatient Facility
Date of Service
_
_
Point of Contact
(If known) MM-DD-YYYY
Evaluate Only
Ordering
_
_
Phone
Evaluate and Treat
Provider
Type of Service
Office
List Specialty
Visit
Surgical/Diagnostic Procedure
Speech Therapy
Hospice
DME
Other
Observation
Home Health
PT/OT
OP Behavioral Health
Acute
f inpatient, please
I
Inpatient Admission:
Rehab
SNF
Care
provide a diagnosis code:
Procedure or
HCPC Code
Facility
Address
_
Zip Code
City
State
Rendering Provider
Address
_
Zip Code
City
State
Presenting symptoms or reason for referral.
Pertinent history, findings and specials situations include known discharge needs if inpatient admission.
TP-2568.7
To assist with timely processing, please complete this form in its entirety.
07/14
Proprietary to Humana Military - Not to be Disclosed